Ethical Conflict and Moral Distress of Intensive Care Nurses in End-of-Life Care: A Systematic Review and Strategies for Enhancing Ethical Decision- Making

Background : Nurses, particularly those working in critical care and palliative settings, often encounter ethical conflicts when facing end-of-life (EoL) situations that involve complex clinical and moral considerations. Repeated exposure to such dilemmas can lead to moral distress. Ethical conflict and moral distress, although conceptually distinct, are closely interrelated phenomena that can significantly influence nurses’ ethical decision-making. Objective : This systematic review has a two-fold objective: (1) to identify and synthesize the principal drivers of ethical conflict and moral distress experienced by nurses in EoL care, and (2) to synthesize and critically evaluate evidence-based, multi-level strategies designed to mitigate moral distress and enhance ethical decision-making. Results : Thematic synthesis revealed three primary drivers: Conflict over Medical Futility, Family-Related Conflicts, and Systemic/Interprofessional Tensions. Synthesized strategies were categorized as Individual-Level (e.g., resilience training), Team-Level (e.g., formal ethics consultations), and Organizational-Level (e.g., transformational leadership). Conclusions : Ethical Conflict in EoL care is a systemic, relational, and organizational problem. While individual strategies offer coping mechanisms, the most effective interventions are systemic, focusing on creating an organizational "just culture," empowering nurses' voices in decision-making, and fostering interprofessional respect.